Healthcare Provider Details

I. General information

NPI: 1316943152
Provider Name (Legal Business Name): SHANE ALLEN MESCHKE LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9549 PENN AVE S
BLOOMINGTON MN
55431-2563
US

IV. Provider business mailing address

13716 ALABAMA AVE S
SAVAGE MN
55378-2460
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-9549
  • Fax: 952-703-3481
Mailing address:
  • Phone: 612-987-5913
  • Fax: 952-703-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7000
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: